NOEES: How much do you know about the new revolution in minimally invasive surgery?

There are many channels in the human body, such as the digestive tract, respiratory tract, reproductive tract, urinary tract, etc. These channels not only have extremely important physiological functions, but also provide operation paths and space for surgical operations, especially minimally invasive operations. When minimally invasive surgery meets the natural channels of the human body, what kind of sparks will the two create? Professor Zhang Jianguo of the Digestive Disease Center of the Air Force General Hospital introduced a new type of minimally invasive surgery - endoscopic surgery through natural channels.

Digestive surgery has undergone epoch-making progress from laparotomy to laparoscopy, and from major invasive to minimally invasive, bringing good news to countless patients. On the basis of ensuring the treatment effect, "minimally invasive rather than major invasive" has become a general consensus in the medical community at home and abroad. However, innovation is endless, and the same is true for minimally invasive surgery. As one of the first doctors in the world to systematically complete gallbladder transurethral endoscopic surgery, we are well aware of the difficulty of innovation in minimally invasive surgery, especially the innovation process from 0 to 1 is extremely challenging. After years of practice, the author found that a new type of minimally invasive surgery-natural channel endoscopic surgery (NOEES) can solve many problems that traditional minimally invasive surgery cannot solve, and can achieve "advanced minimally invasive" and "scarless surgery", which has clinical promotion significance.

Mainly targeting special organs

Endoscopic surgery through natural channels refers to the doctor delivering an endoscope through the natural channels of the human body to the inside of the target organ for direct observation and operation. It should be noted that this type of surgery can be divided into broad and narrow senses. The former includes existing operations such as gastroenteroscopes, respiroscopes, uroscopes, and hysteroscopes, while the latter specifically refers to endoscopic surgery on special organs such as the gallbladder, liver, pancreas, and appendix. Depending on the target organ to be reached, endoscopic surgery through natural channels can be divided into gallbladder endoscopic surgery through natural channels (GB-NOEES), intrahepatic bile duct endoscopic surgery through natural channels (L-NOEES), pancreatic duct endoscopic surgery through natural channels (P-NOEES), and appendix endoscopic surgery through natural channels (A-NOEES). In the future, if it is possible to enter organs such as the ovaries and fallopian tubes through natural channels, then these surgeries can also be classified as endoscopic surgery through natural channels in a narrow sense.

Minimally invasive surgery is more "traceless"

Traditional laparoscopic surgery requires 3 to 4 holes to be made in the patient's abdomen. Even the latest single-hole laparoscopy requires a hole to be made near the patient's navel, which is not a strictly scar-free surgery. The author believes that with the following three advantages, natural channel endoscopic surgery is expected to make surgical operations scar-free and optimize minimally invasive surgery.

First, Tao follows nature. Tao means the surgical path; Fa means to follow. Endoscopic surgery through natural channels is to deliver the endoscope to the target organ along the natural anatomical structure of the human body, so it is said that Tao follows nature.

The second is direct vision. Direct vision operation has unique advantages for early diagnosis, accurate diagnosis, and qualitative diagnosis of target organs.

The third is to preserve organs. Endoscopic surgery through the natural channel does not damage the organs at all, and can completely preserve the normal structure and function of the organs after the operation.

What is the difference of one word?

In fact, the concepts of "natural orifice endoscopic surgery" (NOSES) and "natural orifice endoscopic surgery" (NOTES) have long been used in clinical practice. Although the English abbreviations of these two surgeries and natural orifice endoscopic surgery (NOEES) differ by only one letter, their specific operations are very different.

Natural orifice specimen collection surgery mainly refers to the use of laparoscopes, transanal endoscopes or some soft endoscopes to obtain specimens through natural orifices (rectum or vagina) without auxiliary incisions on the abdominal wall. Whether in terms of surgical purpose or specific operation, this surgery is quite different from natural orifice endoscopic surgery.

Natural orifice endoscopic surgery mainly refers to the use of natural orifices in the human body, such as the mouth, anus, vagina, urethra or visceral perforation, to deliver the endoscope to the target tissue in the abdomen and perform the operation. Among the natural orifice endoscopic surgeries reported so far, the vaginal route is the most widely used and the most mature technology.

"Natural Orifice Trans-luminal Endoscopic Surgery" is a Chinese translation that has been used in China for many years. Its original English name is "Natural Orifice Trans-luminal Endoscopic Surgery (NOTES)".

At present, the translation of "transluminal endoscopic surgery" has certain flaws, mainly in the inaccurate translation of the word "transluminal". In fact, the word means "across the wall", that is, when performing transluminal endoscopic surgery, the endoscope must pass through the incision or puncture in the patient's gastrointestinal tract or vagina to enter the abdominal cavity or pelvic cavity. It is essentially a surgery without scars on the body surface, but with a hole in the body, which is fundamentally different from natural channel endoscopic surgery, which does not make any incisions, punctures or fistulas.

New technologies still need more exploration

For many years, the author has been deeply engaged in the practice and exploration of natural channel endoscopic surgery. So far, the author and his team have successfully completed more than 200 such operations and achieved remarkable results. Patients recover quickly after surgery and are very satisfied with the results of the surgery. Related surgical case reports and technical introductions have been published in journals such as "Surgical Theory and Practice" and "Chinese Journal of Basic and Clinical General Surgery". It is undeniable that the development of natural channel endoscopic surgery still faces some limitations. These limitations mainly include the difficulty of the operation, which requires the surgeon to have a high level of technical skills; the surgical instruments need to be further improved; the cost of the operation is relatively high; and there is a lack of large-sample, multi-center prospective randomized controlled studies.

At the same time, it should be made clear that the development goal of natural channel endoscopic surgery is not to replace the existing minimally invasive surgery in the same field, but to provide patients with a new treatment option. Whether it can become the preferred or first choice treatment method for certain diseases still needs to be determined through more exploration and research.